The peritoneum is the largest and most complexly arranged serous membrane in the body. The potential peritoneal spaces, the peritoneal reflec- tions forming peritoneal ligaments, mesenteries, omenta and the natural flow of peritoneal fluid deter- mine the route of spread of intraperitoneal fluid and, consequently, disease processes within the abdominal cavity. The peritoneal ligaments, mesenteries and omenta also serve as boundaries for disease processes and conduits for disease spread. The peritoneal cavity and its reflections are frequently involved by infec- tious, inflammatory, neoplastic and traumatic pro- cesses. Before the introduction of cross-sectional im- aging, the peritoneum and its reflections could only be imaged with difficulty, often requiring invasive techniques. Computed tomography and, to a lesser extent, sonography and MR imaging allow the accu- rate examination of the complex anatomy of the peri- toneal cavity, which is the key to understanding the pathological processes affecting it. This article re- views the normal peritoneal anatomy and its disease processes.

Review article The peritoneum, mesenteries and omenta: normal anatomy and pathological processes

A technique for noninvasive ultrasound examination to detect and map abdominal wall adhesions is described. The examination is based on the demonstration of movement of abdominal viscera during real-time imaging. This movement is called viscera slide and either occurs spontaneously as a result of respiratory movement or may be induced by manual compression. Abdominal wall adhesions produce a restriction of viscera slide. Ultrasonic demonstration of restricted viscera slide has been used for the precise localization and mapping of abdominal wall adhesions prior to abdominal surgery. The technique may be particularly useful in providing safe initial access in patients undergoing laparoscopy who are at increased risk for trocar injury of viscera due to abdominal wall adhesions resulting from previous surgery or peritonitis.

Technique of ultrasonic detection and mapping of abdominal wall adhesions

Background
The presence of residual tumour after primary debulking surgery is the most important prognostic factor in patients with advanced ovarian cancer. In up to 60% of cases, residual tumour of more than 1 cm is left behind, stressing the necessity of accurately selecting those patients who should be treated with primary debulking surgery and those who should receive neoadjuvant chemotherapy instead.

Objectives
To determine if performing an open laparoscopy after the diagnostic work-up of patients suspected of advanced ovarian cancer is accurate in predicting the resectability of disease.

Search methods
We searched MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Register of Diagnostic Test Accuracy Studies, MEDION and ISI Web of Science to February 2013. Furthermore, we checked references of identified primary studies and review articles.

Selection criteria
We included studies that evaluated the diagnostic accuracy of laparoscopy to determine the resectability of disease in patients who are suspected of advanced ovarian cancer and planned to receive primary debulking surgery.

Data collection and analysis
Two review authors assessed the quality of included studies using QUADAS-2 and extracted data on study and patients' characteristics, index test, target condition and reference standard. Data for two-by-two tables were extracted and summarised graphically. Sensitivity and specificity and negative predictive values were calculated.

Main results
We included seven studies reporting on six cohorts. Between 27% to 64% of included patients per study were positive on laparoscopy (too extensive disease to warrant laparotomy) and between 36% to 73% were negative (disease suitable for debulking laparotomy). Only two studies avoided partial verification bias and provided data to calculate sensitivity and specificity, which did not justify meta-analysis. These two studies had a sensitivity of 0.70 (95% confidence interval (CI) 0.57 to 0.82) and 0.71 (95% CI 0.44 to 0.90); however, the specificity of both studies was 1.00 (95% CI 0.90 to 1.00). In these two studies there were no false positives, i.e. no patients for whom laparoscopy indicated that major surgery would not be successful and should be avoided, whereas, in reality the patient could be successfully operated upon. Negative predictive values (NPV), for those patients who were diagnosed with having not too extensive disease correctly identified were 0.75 (95% CI 0.55 to 0.86) and 0.96 (95% CI 0.56 to 0.99) due to a different prevalence. Although the studies did report sufficient data to calculate NPVs, we judged these estimates too heterogeneous to meta-analyse.

Three studies described the development or validation of a prediction model with a clear cut-off for test positivity. Sensitivity and specificity of these prediction models were 0.30 to 0.70 and 0.89 to 1.00, respectively. However, one of these studies suffered from partial verification bias.

Authors' conclusions
Laparoscopy is a promising test, but the low number of studies and the differences between the included studies do not allow firm conclusions to be drawn from these data. Due to a difference in prevalence, there is a wide range in negative predictive values between studies. Two studies verified all patients. These imply a high specificity of laparoscopy in diagnosing resectability and have a good sensitivity. Both studies show that the use of criteria for unresectable disease will result in no patients inappropriately unexplored. However, there will still be patients undergoing unsuccessful primary laparotomy. Using a prediction model does not increase the sensitivity and will result in more unnecessarily explored patients, due to a lower specificity.

/pdf/laparoscopy-for-diagnosing-resectability-of-disease-in-2nxsnvyxs7.pdf

Laparoscopy for diagnosing resectability of disease in patients with advanced ovarian cancer

Laparoscopic candidates with abdominal scars may have adhesions that result in visceral injury during trocar insertion. The purpose of this study was to evaluate the use of preoperative ultrasound mapping of abdominal wall adhesions, to provide safe initial laparoscopic access, and to guide the placement of subsequent trocars, facilitating adhesolysis when necessary. Thirty consecutive patients with previous abdominal surgery who were scheduled for laparoscopy underwent a preoperative ultrasonic examination of the abdominal wall using a 7-MHz linear ultrasound probe. Spontaneous viscera slide was measured during longitudinal scanning (normal=2–5 cm) and induced viscera slide was evaluated during longitudinal and transverse scanning (normal=1 cm or more) over the existing abdominal scar, the peri-umbilical region, and the remaining abdominal quadrants. Sixteen (53%) of 30 patients had adhesions under their scar and only four patients (25%) had umbilical adhesions. The 12 patients without umbilical adhesions all had successful closed cannulation while open cannulation at alternate sites was successful in the four individuals with umbilical adhesions. Blind umbilical needle cannulation was successfully done in all of the remaining 14 patients (47%) without visceral injury, including three patients (21%) with upper abdominal scars who were adhesion-free elsewhere. No adhesions were encountered that had not been preoperatively predicted by ultrasound. We conclude that examination of the abdominal wall with spontaneous and induced viscera slide, using ultrasound scanning, can reliably detect intraabdominal adhesions. The examination is best done on a highly selective basis by the operating surgeon to guide the location for initial trocar insertion and determine the type of abdominal wall cannulation in those individuals with previous abdominal scars.

The ultrasonic localization of abdominal wall adhesions.

Background: We set out to investigate prospectively the morbidity rate for gynecological laparoscopy patients at a tertiary care center. Methods: We prospectively recorded data on 743 laparoscopic procedures performed between January 1, 1992 and December 31, 1996. The procedures included 36 diagnostic laparoscopies (4.8%), 115 laparoscopies carried out for minor surgical acts (15.4%), 523 for major surgical acts (70.4%), and 69 for advanced surgical acts (9.4%). A total of 127 patients had a history of prior laparotomy (17%). All those procedures were performed by young senior surgeons. We defined a complication as an event that had modified the usual course of the procedure or of the postoperative period. For statistical analysis, we used the chi-squared test or Fisher’s exact test. Results: Complications occurred in 22 cases; the overall complication rate was 2.9% when all events were considered. One complication (injury of the left primitive iliac artery) was related to insertion of the Veress needle (0.13%). A total of 2,578 trocars were inserted, giving rise to 10 complications (1.3%). Three unintended laparotomies were required for bowel or bladder injuries (0.4%). Finally, the introduction of the laparoscope was responsible for 11 complications (1.4%); this figure represents 50% of all the complications of this series. Eight intraoperative complications (1%) occurred during the laparoscopic surgery (seven severe bleedings and one ureter injury, but no intestinal lesions); laparotomy was required in six of these cases. Three complications occurred during the postoperative stage: one granulomatous peritonitis after intraabdominal rupture of a dermoid cyst, one incisional hernia, and a fastresolving cardiac arrhythmia. Conclusions: In our experience, operative gynecological laparoscopy is associated with an acceptable morbidity rate. Moreover, about half of the complications occur during the installation of the laparoscopic procedure, underscoring the usefulness of safety rules.

Morbidity in laparoscopic gynecological surgery: results of a prospective single-center study.

Through the use of echography after establishing the pneumoperitoneum, it is possible to recognize the presence of intra-abdominal adhesions and the distribution of gas. Using this method, the laparoscopist is able to form a picture of the intra-abdominal situation with regard to the site of the adhesions and the pneumoperitoneal chambers. This enables him to choose the best site for the insertion of the trocar both for the avoidance of possible incidents, and for optimal inspection. This method has been successfully employed in 39 patients with large abdominal surgical scars. Laparoscopy confirmed the echographic findings in almost all the cases. Thus, in 38% of cases the laparoscopic "inspection site" chosen was atypical with respect to the usual sites for the insertion of the laparoscope, but always proved to be the most suitable.

Prelaparoscopic echography used to detect abdominal adhesions.

Laparoscopy in staging, follow-up, and restaging of ovarian carcinoma

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Prelaparoscopic echography used to detect abdominal adhesions.

Laparoscopy in staging, follow-up, and restaging of ovarian carcinoma